Questionnaires and observation tools for breathing pattern disorder show mixed evidence in systematic review

A systematic review published in BMC Pulmonary Medicine has examined how well the assessment tools that physiotherapists use to evaluate breathing pattern disorder actually perform, and the answer is that the evidence base remains uneven. The review, which applied the COSMIN methodology for judging the quality of measurement studies, found that only three instruments have been evaluated in enough detail to draw conclusions, and even the best-studied of these showed substantial inconsistency across studies.

Breathing pattern disorder is increasingly recognised as a contributor to breathlessness, a symptom that brings many patients to respiratory clinics. In routine evaluation, physiotherapists commonly rely on symptom-based questionnaires and structured clinical observations, yet the measurement properties of these instruments, including their reliability, validity and responsiveness, have remained unclear. The review was designed to address that gap directly.

The researchers searched Embase, PubMed, MEDLINE and PEDro from database inception to July 2023, with an update in December 2025 that also included reference lists. They included studies evaluating patient-reported outcome measures, clinician-reported outcome measures, or performance-based outcome measures, and assessed the methodological quality of each study using the COSMIN risk of bias checklist.

Eighteen studies met the inclusion criteria. Together they evaluated three instruments: the Nijmegen Questionnaire, the Self-Evaluation of Breathing Questionnaire, and the Breathing Pattern Assessment Tool, known as BPAT.

The Nijmegen Questionnaire had the most extensive evidence base of the three, but the review found substantial heterogeneity across the studies that examined it, meaning that estimates of its measurement properties varied considerably from one study to another. This heterogeneity complicates any simple judgement about how the questionnaire should be used in practice.

The BPAT showed a different pattern. It demonstrated moderate-certainty evidence for inter-rater reliability in specialist clinical settings, suggesting that different trained assessors can reach similar ratings when using the tool in those environments. However, evidence for its other measurement properties was limited, leaving important questions about validity and responsiveness unanswered.

Evidence supporting the Self-Evaluation of Breathing Questionnaire in symptomatic populations was also limited, according to the review. The authors concluded that the Nijmegen Questionnaire and BPAT may support assessment when interpreted within their limitations, but that neither should be used as a standalone diagnostic tool.

Instead, the review recommends a multimodal approach that combines symptom-based questionnaires with structured clinical observation. The authors also emphasise that further high-quality studies are needed to establish robust, standardised outcome measures for breathing pattern disorder, noting that the current evidence base is not yet sufficient to identify a single best instrument.

For clinicians, the practical message is one of caution: the available tools can contribute to assessment, but their results should be interpreted alongside a broader clinical evaluation rather than treated as definitive. For researchers, the review highlights where the evidence gaps lie, particularly around the validity and responsiveness of these measures in the populations where they are most often applied.

Subject of Research: Measurement properties of physiotherapy assessment tools for breathing pattern disorder in adults with breathlessness

Article Title: Measurement properties of physiotherapy assessment tools for breathing pattern disorder in adults with breathlessness: a systematic review using COSMIN methodology

Article References: Grillo, L., Smith, S., Kilduff, J., Osman, L., Hull, J., Russell, A., Hopkinson, N., Bloom, C., & Shannon, H. (2026). Measurement properties of physiotherapy assessment tools for breathing pattern disorder in adults with breathlessness: a systematic review using COSMIN methodology. BMC Pulmonary Medicine. https://doi.org/10.1186/s12890-026-04795-x

Image Credits: AI Generated

DOI: 10.1186/s12890-026-04795-x

Keywords: breathing pattern disorder, breathlessness, physiotherapy, systematic review, COSMIN, Nijmegen Questionnaire, Self-Evaluation of Breathing Questionnaire, BPAT, reliability, validity, measurement properties, respiratory assessment